Managing Bipolar Disorder patients during COVID‐19 outbreak

To the Editors,

On February 20, 2020 the first case of coronavirus disease (COVID‐19) was diagnosed in Italy. In a few weeks the Policlinico A. Gemelli Hospital in Rome became a so called “COVID Hospital”, so its structure changed and consequently also the organization of the clinical activities of the Psychiatric Unit. In particular, outpatient services (ambulatory and day hospital) have guaranteed the management of emergencies, the administration of oral and long acting drug therapies, and the assistance of patients with severe mental illness by means of telephone checks.

The pandemic affects everyone, but some groups are especially impacted: people with mental illnesses already suffer higher rates of chronic medical conditions and have a shortened lifespan, so psychiatric patients should be considered an extremely vulnerable population in the COVID‐19 pandemic. COVID‐19 has an impact on mental health either directly or indirectly.

Bipolar Disorder (BD) is a chronic affective disorder characterized by dramatic shifts in mood, thinking, behaviour and energy. It is well known that psychosocial factors show a significant impact on the variability observed in the evolution and course of affective symptoms: the quality of family relationships and social support plays an important role in the evolution of the disease and adverse life events can either precipitate the occurrence of an episode or postpone a full recovery. In these patients the lock‐down associated with COVID‐19 pandemic has a high probability to function as a trigger for a more severe and unstable illness course characterized by increased risk of depressive or maniacal relapse, affective lability, impulsivity, and risk‐taking behaviour, alcohol or substance use disorders, and higher rates of suicide attempts. The trauma load may play a significant role in BD patients. The Central Italy was particularly stuck during the last years (in 2009 in the region of Abruzzo and in 2016 in the regions of Lazio, Marche, Umbra and Abruzzo) by destructive earthquakes and consequent economic crisis, making people more vulnerable to psychiatric disorders and increasing psychiatric relapses and hospitalizations. So a “dark triad” (earthquakes, economic crisis, and COVID‐19) has hit Central Italy in a massive way in the recent years. ¹

As in other hospitals, our Department has faced various health, administrative and personnel management difficulties. In the meantime, in the Emergency Ward room a “clean” area was created, where the triage of psychiatric patients is carried out in order to be evaluated by the psychiatrist. Each patient is necessary treated as possible infected, therefore all the operators must wear the appropriate personal protective equipment and social distancing is carefully respected. Consultation‐liaison psychiatry in the acute medical settings has a great importance during this emergency: patients concerning COVID‐19 are likely to be vulnerable to delirium, agitation, and decompensations of psychosis or mood disorders, necessitating psychiatric evaluation.

While the COVID‐19 pandemic progressed, our medical and paramedical staff have faced increased work activity and emotional stress, due to the contemporary management of new work and family needs, daily fear of possible infection for themselves and their own family members, and the frustration of waiting for the results of nasal swabs performed. Nevertheless, we have tried to raise our efforts to maintain continuity of care for existing patients and try to prevent exacerbation of underlying psychiatric disorders due to the psychosocial consequences of the COVID‐19 pandemic: economic difficulties, job layoffs, prolonged school and business closings, isolation, disruption of habitual patterns of sleep and wakefulness, continuous bombing through media and social of threatening news. Some of our patients have confined themselves to indoor spaces and can communicate with their loved ones only through the use of electronic tools. This may have a detrimental effect on mood, especially for adults over the age of 65, who may be less comfortable with internet or mobile phone. Also women are at high risk: it has been outlined that women reported significant higher posttraumatic stress symptoms in China in the hardest‐hit areas during COVID‐19 outbreak, particularly in the domains of re‐experiencing, negative alterations in cognition or mood, and hyperarousal. Besides, particularly in women, there is an adjunctive risk of alcohol consumption, eating disorders comorbidity and intimate partner violence during lock‐down. ²

Increased depression and suicidality as well as increased proinflammatory and decreased anti‐viral immune responses may further enhance the susceptibility of this population to COVID‐19. Patients with organic comorbidities are at elevated risk of contagious, and there is a frequent association between BD and a variety of medical disorders.

Our outpatient unit was rearranged and dedicated to emergencies, assuring at least 1 m of distance between patients and operators, face masks, gloves, and continuous sterility procedures. ³ Support hotlines during which mental health professionals could reach out to patients and screen for symptoms of anxiety and depression have been guaranteed. These measures could improve compliance with social distancing, help reduce the impact of COVID‐19 on pre‐existing fragility and allow for personal adjustment to face the situation and control behavioral and emotional responses. We have noticed that telephonic counseling was more efficacious on increased emotional distress in many cases and helped to cope with negative psychological effects including posttraumatic stress symptoms, confusion, anger, frustration, and boredom. Some patients needed medication dosage adjustment: we have created a network with family doctors to respond to patients’ particular needs and to ensure personalized strategy treatments. Patients already involved in psychoeducational groups had the opportunity to continue online meetings, while other have been successfully involved in virtual group‐based behavioral strategies to reduce somatic distress and autonomic hyperarousal (meditation, yoga, mindfulness). Digital tools allow to intervene remotely to minimize face‐to‐face contact without compromising care and contribute to help as many patients as possible. Notwithstanding the general distress associated with a disease outbreak, the disruption of number and quality of social contacts and activities and the reduced access to treatment during quarantine, our team was able to continue to receive data regarding patients’ state, to guarantee psychoeducation, information and psychosocial support by telemedicine, to ensure mail‐order dispensation of prescriptions and to offer day hospital treatment of emergencies. It resulted particularly important to investigate about suicidal ideation or potential violence in order to prevent crisis situations, to address empathy and focus on the individual resilience and the reciprocal respect and help.

CONFLICT OF INTERESTS

The authors declare no conflict of interests.